Bilateral chronic common carotid occlusion
Increasing confusion but no focal neurological deficit
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Hypertrophied vertebral arteries with occlusion of both common carotids at their origins, Intracranial arteries (MCA and ACA) are filling normally being supplied by a dominant right posterior communicating artery. Note external carotid branches are patent being fed by vertebral and subclavian branch collaterals.
If arterial occlusion occurs over a prolonged period, collaterals can develop. In this case external carotid branches have remained patent and intracranial arteries are being fed by a well developed circle of Willis.